Behavioral Health

Emergency Department Attending Physician Variation in Opioid Prescribing in Low Acuity Back Pain

Hoppe, DO, et al.

Despite treatment guidelines suggesting alternatives, as well as evidence of a lack of benefit and evidence of poor long-term outcomes, opioid analgesics are commonly prescribed for back pain from the emergency department (ED). Variability in opioid prescribing suggests a lack of consensus and an opportunity to standardize and improve care. We evaluated the variation in attending emergency physician (EP) opioid prescribing for patients with uncomplicated, low acuity back pain (LABP).

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Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review

Barata, MD, MBA, et al.

Alcohol use disorders (AUD) place a significant burden on individuals and society. The emergency department (ED) offers a unique opportunity to address AUD with brief screening tools and early intervention. We undertook a systematic review of the effectiveness of ED brief interventions for patients identified through screening who are at risk for AUD, and the effectiveness of these interventions at reducing alcohol intake and preventing alcohol-related injuries.

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Involuntary Psychiatric Holds in Preadolescent Children

Santillanes, MD, et al.

Little is known about the use of involuntary psychiatric holds in preadolescent children. The primary objective was to characterize patients under the age of 10 years on involuntary psychiatric holds. We collected demographic data including age, gender, ethnicity and details about living situation, child protective services involvement and prior mental health treatment, as well as ED disposition.

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Effect Of A “No Superuser Opioid Prescription” Policy On ED Visits And Statewide Opioid Prescription

Kahler, MD, MS, et al.

The U.S. opioid epidemic has highlighted the need to identify patients at risk of opioid abuse and overdose. We initiated a novel emergency department- (ED) based interventional protocol to transition our superuser patients from the ED to an outpatient chronic pain program. The objective was to evaluate the protocol’s effect on superusers’ annual ED visits.

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American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations

Michael P. Wilson, MD, PhD et al.

The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs.

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Managing Acute Behavioural Disturbances in the Emergency Department Using the Environment, Policies and Practices: A Systematic Review

Tracey J. Weiland, MPsych/PhD, MAPS, et al.

Effective strategies for managing acute behavioural disturbances (ABDs) within emergency departments (EDs) are needed given their rising occurrence and negative impact on safety, psychological wellbeing, and staff turnover. Our objective was to systematically review the efficacy of strategies for ABD management within EDs that involved changes to environment, architecture, policy and practice.

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American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines

Author Affiliation Eric L. Anderson, MD University of Maryland, Department of Psychiatry, College Park, Maryland Kimberly Nordstrom, MD, JD University of Colorado School of Medicine, Department of Psychiatry, Aurora, Colorado; Denver Health Medical Center, Emergency Psychiatry, Denver, Colorado Michael P. Wilson, MD, PhD Department of Emergency Medicine Behavioral Emergencies Research lab, University of Arkansas for […]

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The Peregrinating Psychiatric Patient in the Emergency Department

The Peregrinating Psychiatric Patient in the Emergency Department
Scott Simpson, MD, MPH et al.

Many emergency department (ED) psychiatric patients present after traveling. Although such travel, or peregrination, has long been associated with factitious disorder, other diagnoses are more common among travelers, including psychotic disorders, personality disorders, and substance abuse. Travelers’ intense psychopathology, disrupted social networks, lack of collateral informants, and unawareness of local resources complicate treatment. These patients can consume disproportionate time and resources from emergency providers. We review the literature on the emergency psychiatric treatment of peregrinating patients and use case examples to illustrate common presentations and treatment strategies. Difficulties in studying this population and suggestions for future research are discussed.

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Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions

Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions
Chun Nuk Lam, MPH, et al.

Patients with mental health conditions frequently use emergency medical services. Many suffer from substance use and homelessness. If they use the emergency department (ED) as their primary source of care, potentially preventable frequent ED revisits and hospital readmissions can worsen an already crowded healthcare system. However, the magnitude to which homelessness affects health service utilization among patients with mental health conditions remains unclear in the medical community. This study assessed the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental health conditions in an urban, safety-net hospital.

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ED Patients with Prolonged Complaints and Repeat ED Visits Have an Increased Risk of Depression

ED Patients with Prolonged Complaints and Repeat ED Visits Have an Increased Risk of Depression
Kristopher R. Brickman, MD et al.

The objective of this study was to explore associations between presenting chief complaints of prolonged symptomatology, patient usage of the emergency department (ED), and underlying depression so that emergency physicians may better target patients for depression screening.

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Case Series of Synthetic Cannabinoid Intoxication from One Toxicology Center

Volume 17, Issue 3, May 2016
Kenneth D. Katz, MD, et al.

Synthetic cannabinoid use has risen at alarming rates. This case series describes 11 patients exposed to the synthetic cannabinoid, MAB-CHMINACA who presented to an emergency department with life-threatening toxicity including obtundation, severe agitation, seizures and death. All patients required sedatives for agitation, nine required endotracheal intubation, three experienced seizures, and one developed hyperthermia. One developed anoxic brain injury, rhabdomyolysis and died. A significant number were pediatric patients. The mainstay of treatment was aggressive sedation and respiratory support. Synthetic cannabinoids pose a major public health risk. Emergency physicians must be aware of their clinical presentation, diagnosis and treatment.

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Gender Differences in Emergency Department Visits and Detox Referrals for Illicit and Nonmedical Use of Opioids

Volume 17, Issue 3, May 2016
Hyeon-Ju Ryoo, BA et al.

Introduction: Visits to the emergency department (ED) for use of illicit drugs and opioids have increased in the past decade. In the ED, little is known about how gender may play a role in drug-related visits and referrals to treatment. This study performs gender-based comparison analyses of drug-related ED visits nationwide.
Methods: We performed a cross-sectional analysis with data collected from 2004 to 2011 by the Drug Abuse Warning Network (DAWN). All data were coded to capture major drug categories and opioids. We used logistic regression models to find associations between gender and odds of referral to treatment programs. A second set of models were controlled for patient “seeking detox,” or patient explicitly requesting for detox referral.
Results: Of the 27.9 million ED visits related to drug use in the DAWN database, visits by men were 2.69 times more likely to involve illicit drugs than visits by women (95% CI [2.56, 2.80]). Men were more likely than women to be referred to detox programs for any illicit drugs (OR 1.12, 95% CI [1.02–1.22]), for each of the major illicit drugs (e.g., cocaine: OR 1.27, 95% CI [1.15–1.40]), and for prescription opioids (OR 1.30, 95% CI [1.17–1.43]). This significant association prevailed after controlling for “seeking detox.”
Conclusion: Women are less likely to receive referrals to detox programs than men when presenting to the ED regardless of whether they are “seeking detox.” Future research may help determine the cause for this gender-based difference and its significance for healthcare costs and health outcomes.

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Variations in Substance Use Prevalence Estimates and Need for Interventions among Adult Emergency Department Patients Based on Different Screening Strategies Using the ASSIST

Volume 17, Issue 3, May 2016
Roland C. Merchant, MD, MPH, ScD

Introduction: Among adult emergency department (ED) patients, we sought to examine how estimates of substance use prevalence and the need for interventions can differ, based on the type of screening and assessment strategies employed.
Methods: We estimated the prevalence of substance use and the need for interventions using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in a secondary analysis of data from two cross-sectional studies using random samples of English- or Spanish-speaking 18–64-year-old ED patients. In addition, the test performance characteristics of three simplified screening strategies consisting of selected questions from the ASSIST (lifetime use, past three-month use, and past three-month frequency of use) to identify patients in need of a possible intervention were compared against using the full ASSIST.
Results: Of 6,432 adult ED patients, the median age was 37 years-old, 56.6% were female, and 61.6% were white. Estimated substance use prevalence among this population differed by how it was measured (lifetime use, past three-month use, past three-month frequency of use, or need for interventions). As compared to using the full ASSIST, the predictive value and accuracy to identify patients in need of any intervention was best for a simplified strategy asking about past three-month substance use. A strategy asking about daily/near-daily use was better in identifying patients needing intensive interventions. However, some patients needing interventions were missed when using these simplified strategies.
Conclusion: Substance use prevalence estimates and identification of ED patients needing interventions differ by screening strategies used. EDs should carefully select strategies to identify patients in need of substance use interventions.

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Impact of Mental Health and Substance Use Disorders on Emergency Department Visit Outcomes for HIV Patients

Volume 17, Issue 2, March 2016.
Brian Y. Choi, MD, MPH, et al.

Introduction: A disproportionate number of individuals with human immunodeficiency virus (HIV)
have mental health and substance-use disorders (MHSUDs), and MHSUDs are significantly
associated with their emergency department (ED) visits. With an increasing share of older adults
among HIV patients, this study investigated the associations of MHSUDs with ED outcomes of HIV
patients in four age groups: 21-34, 35-49, 50-64, and 65+ years.
Methods: We used the 2012 Nationwide Emergency Department Sample (NEDS) dataset (unweighted
n=23,244,819 ED events by patients aged 21+, including 115,656 visits by patients with
HIV). Multinomial and binary logistic regression analyses, with “treat-and-release” as the base
outcome, were used to examine associations between ED outcomes and MHSUDs among visits that
included a HIV diagnosis in each age group.
Results: Mood and “other” mental disorders had small effects on ED-to-hospital admissions, as
opposed to treat-and-release, in age groups younger than 65+ years, while suicide attempts had
medium effects (RRR=3.56, CI [2.69-4.70]; RRR=4.44, CI [3.72-5.30]; and RRR=5.64, CI [4.38-
7.26] in the 21-34, 35-49, and 50-64 age groups, respectively). Cognitive disorders had mediumto-large
effects on hospital admissions in all age groups and large effects on death in the 35-49
(RRR=7.29, CI [3.90-13.62]) and 50-64 (RRR=5.38, CI [3.39-8.55]) age groups. Alcohol use
disorders (AUDs) had small effects on hospital admission in all age groups (RRR=2.35, 95% CI
[1.92-2.87]; RRR=2.15, 95% CI [1.95-2.37]; RRR=1.92, 95% CI [1.73-2.12]; and OR=1.93, 95%
CI [1.20-3.10] in the 21-34, 35-49, 50-64, and 65+ age groups, respectively). Drug use disorders
(DUDs) had small-to-medium effects on hospital admission (RRR=4.40, 95% CI [3.87-5.0];
RRR=4.07, 95% CI [3.77-4.40]; RRR=4.17, 95% CI [3.83-4.55]; and OR=2.53, 95% CI [2.70-
3.78] in the 21-34, 35-49, 50-64, and 65+ age groups, respectively). AUDs and DUDs were also
significantly related to the risk of death, and DUDs had a small effect on the risk of discharge
against medical advice in the 35-49 and 50-64 age groups.
Conclusion: The high prevalence of MHSUDs and their significant roles in ED visit outcomes in
patients with HIV provide support for integrated care for these patients outside the ED to reduce
their ED visits and costly hospital admissions and institutional care that follows, especially for the
increasing numbers of older adults with HIV.

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Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting

Volume 17, Issue 2, March 2016.
Scott L. Zeller, MD, et al.

Introduction: Patient agitation represents a significant challenge in the emergency department
(ED), a setting in which medical staff are working under pressure dealing with a diverse range of
medical emergencies. The potential for escalation into aggressive behavior, putting patients, staff,
and others at risk, makes it imperative to address agitated behavior rapidly and efficiently. Time
constraints and limited access to specialist psychiatric support have in the past led to the strategy
of “restrain and sedate,” which was believed to represent the optimal approach; however, it is
increasingly recognized that more patient-centered approaches result in improved outcomes. The
objective of this review is to raise awareness of best practices for the management of agitation in the
ED and to consider the role of new pharmacologic interventions in this setting.
Discussion: The Best practices in Evaluation and Treatment of Agitation (BETA) guidelines
address the complete management of agitation, including triage, diagnosis, interpersonal
calming skills, and medicine choices. Since their publication in 2012, there have been further
developments in pharmacologic approaches for dealing with agitation, including both new agents
and new modes of delivery, which increase the options available for both patients and physicians.
Newer modes of delivery that could be useful in rapidly managing agitation include inhaled, buccal/
sublingual and intranasal formulations. To date, the only formulation administered via a nonintramuscular
route with a specific indication for agitation associated with bipolar or schizophrenia
is inhaled loxapine. Non-invasive formulations, although requiring cooperation from patients, have
the potential to improve overall patient experience, thereby improving future cooperation between
patients and healthcare providers.
Conclusion: Management of agitation in the ED should encompass a patient-centered approach,
incorporating non-pharmacologic approaches if feasible. Where pharmacologic intervention is
necessary, a cooperative approach using non-invasive medications should be employed where

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Care of Psychiatric Patients: The Challenge to Emergency Physicians

Volume 17, Issue 2, March 2016.
Leslie Zun, MD, MBA, et al.

Psychiatric patients frequently present to the emergency
department (ED) for care when they are in crisis. Recent
studies demonstrate about 10% of all ED patients present with
psychiatric illness. However, this is not an adequate estimate
of the number of patients because many of these patients do
not have a psychiatric diagnosis. Two recent studies have
demonstrated that 45% of adults and 40% of pediatric patients
who present to the ED with non-psychiatric complaints have
undiagnosed mental illness. These studies did not determine
whether these psychiatric illnesses affected the patients’
presentation. The purpose of this article is to discuss disparity
and challenges in caring for these patients.

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Emergency Department Visits by Older Adults with Mental Illness in North Carolina

Volume 16, Issue 7, December 2015.
Anne M. Hakenewerth, PhD, et al.

Introduction: We analyzed emergency department (ED) visits by patients with mental health disorders
(MHDs) in North Carolina from 2008-2010 to determine frequencies and characteristics of ED visits by
older adults with MHDs.
Methods: We extracted ED visit data from the North Carolina Disease Event Tracking and Epidemiologic
Collection Tool (NC DETECT). We defined mental health visits as visits with a mental health ICD-9-CM
diagnostic code, and organized MHDs into clinically similar groups for analysis.
Results: Those ≥65 with MHDs accounted for 27.3% of all MHD ED visits, and 51.2% were admitted. The
most common MHD diagnoses for this age group were psychosis, and stress/anxiety/depression.
Conclusion: Older adults with MHDs account for over one-quarter of ED patients with MHDs, and their
numbers will continue to increase as the “boomer” population ages. We must anticipate and prepare for
the MHD-related needs of the elderly.

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Alcohol Use as Risk Factors for Older Adults’ Emergency Department Visits: A Latent Class Analysis

Volume 16, Issue 7, December 2015.
Namkee G. Choi, PhD, et al.

Introduction: Late middle-aged and older adults’ share of emergency department (ED) visits is increasing
more than other age groups. ED visits by individuals with substance-related problems are also increasing.
This paper was intended to identify subgroups of individuals aged 50+ by their risk for ED visits by
examining their health/mental health status and alcohol use patterns.
Methods: Data came from the 2013 National Health Interview Survey’s Sample Adult file (n=15,713).
Following descriptive analysis of sample characteristics by alcohol use patterns, latent class analysis
(LCA) modeling was fit using alcohol use pattern (lifetime abstainers, ex-drinkers, current infrequent/light/
moderate drinkers, and current heavy drinkers), chronic health and mental health status, and past-year
ED visits as indicators.
Results: LCA identified a four-class model. All members of Class 1 (35% of the sample; lowest-risk
group) were infrequent/light/moderate drinkers and exhibited the lowest probabilities of chronic health/
mental health problems; Class 2 (21%; low-risk group) consisted entirely of lifetime abstainers and,
despite being the oldest group, exhibited low probabilities of health/mental health problems; Class 3
(37%; moderate-risk group) was evenly divided between ex-drinkers and heavy drinkers; and Class 4
(7%; high-risk group) included all four groups of drinkers but more ex-drinkers. In addition, Class 4 had
the highest probabilities of chronic health/mental problems, unhealthy behaviors, and repeat ED visits,
with the highest proportion of Blacks and the lowest proportions of college graduates and employed
persons, indicating significant roles of these risk factors.
Conclusion: Alcohol nonuse/use (and quantity of use) and chronic health conditions are significant
contributors to varying levels of ED visit risk. Clinicians need to help heavy-drinking older adults reduce
unhealthy alcohol consumption and help both heavy drinkers and ex-drinkers improve chronic illnesses

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Contact Information

WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
Phone: 1-714-456-6389


ISSN: 1936-900X
e-ISSN: 1936-9018

ISSN: 2474-252X

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.